No recess due to asthma

[SandIsMyGlitterRN, BSN, RN]

A parent wants me to not allow their student outside if it is under 55 degrees outside.  What do you do with those students?  Do they sit in the clinic?  The doctor's note reads the student can be outside but not an extended amount of time?  What is an extended amount of time?  I am having a hard time reaching the doctor for clarification.  Do we go by what the parent wants or by the doctor?

[Cattz, ADN]

A few questions come to mind. Is the child's asthma under control? What does the Asthma Action Plan indicate? If the child seems like they're feeling well-  I'd tell the parent that until the Dr clarifies further- the child will be going outside with their classmates. I wouldn't think that 30 -45 minutes is considered an extended time. How long is recess. Document all the times you've tried to reach the Dr. Can you fax a note to the Dr. office? Is it a local family Dr or at a bigger hospital?

If the child has to stay inside. I'd have them sit in the office. If the child isn't ill- it's too busy and no need to expose the child to sick students that could be coming in and out.

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[SandIsMyGlitterRN, BSN, RN]

I have never had to treat this student in clinic for their asthma in the the past 2 years.  The AAP does not mention anything about temperature.  The letter came from an urgent care physician.  Recess is 30 minutes.  

[k1p1ssk, BSN, RN]

I wouldn't go by the parent's ask, I would follow the urgent care letter. I wouldn't call 30minutes an extended period of time, but maybe you compromise and tell the parent that based on your understanding of the letter, the student will go out for 15 minutes and then be called in. I would bet the kid gets so annoyed by being called in every day the issue will be dropped. And then, you can use malicious compliance in your favor and ask for a letter from the provider releasing the restriction. 

Alternatively, you can let the parents know you need more specific parameters from the child's primary care physician or whatever specialist physician treats their asthma - not an urgent care doctor. Remind the parent that the kid will have to sit outside the office every day and miss out on playing with their friends - depending on where you live, this could be MONTHS of missed recess. In my part of the country, we only have 4 months of the school year where above 55 is the norm during recess times.

You could also suggest they get orders that will allow you to pre-treat with albuterol before they go outside.  

I liken this to a kid with a fracture - they go to an ED and you get an initial excuse/restriction note from the treating ED doctor, but the kid usually follows up with ortho and THEY provide the RTP notes. 

[JohnHood, BSN]

The parent is just that, the parent and ultimate authority for their child. It really does not matter what the doctor says. I would interpret the doctor's note as it is okay for the child to be outside long enough to change classes or to go from one building to another.

[NutmeggeRN, BSN]

JohnHood said:

The parent is just that, the parent and ultimate authority for their child. It really does not matter what the doctor says. I would interpret the doctor's note as it is okay for the child to be outside long enough to change classes or to go from one building to another.

Respectfully disagree. If we did everything a parent wanted, we would spend all day doing that and nothing else. 

[k1p1ssk, BSN, RN]

NutmeggeRN said:

Respectfully disagree. If we did everything a parent wanted, we would spend all day doing that and nothing else. 

So true! School nurses follow doctor's orders, just like nurses in other settings, and it is a nurse's responsibility to clarify an order with the physician, NOT the patient or their caregivers. 

[SandIsMyGlitterRN, BSN, RN]

I think the parent may be doctor shopping.  She is now giving me a note from another urgent care that states 10 minutes outside only.  

[darnold38, BSN, RN]

SandIsMyGlitterRN said:

I think the parent may be doctor shopping.  She is now giving me a note from another urgent care that states 10 minutes outside only.  

If all the child can do is 10 minutes of exercise it sounds like the asthma isn't controlled or it's exercise induced which would require albuterol before exercise. Has the child been followed up with their PCP or asthma specialist? With this strict restriction they should've been. I'd continue trying to contact their PCP and/or asthma specialist if for no other reason than to alert them to all these goings on and to get clarification. And yes this parent seems to be doctor shopping. I'm surprised the second note doesn't mention temperature.